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Green-top Guideline MANAGEMENT OF ACUTE PELVIC INFLAMMATORY DISEASE
This is the second edition of this guideline, which was previously published in 2003 under the same title.Purpose and scope
Pelvic inflammatory disease (PID) is usually the result of infection ascending from the endocervix causing
endometritis, salpingitis, parametritis, oophoritis, tubo-ovarian abscess and/or pelvic peritonitis. While sexually
transmitted infections (STIs) such as Chlamydia trachomatis and Neisseria gonorrhoeae have been identified
as causative agents, additional STIs including Mycoplasma genitalium, anaerobes and other organisms may
PID is a common cause of morbidity and accounts for one in 60 general practitioner consultations by women
under the age of 45 years.6 Delays of only a few days in receiving appropriate treatment markedly increase
the risk of sequelae, which include infertility, ectopic pregnancy and chronic pelvic pain.7,8 Sequelae may also
have significant healthcare costs.9 This guideline applies to women requiring treatment for confirmed or
suspected acute PID being treated in an outpatient or inpatient setting by primary and secondary care
There are marked variations in the antimicrobial regimens used in the treatment of PID, reflecting uncertainty
in the optimal treatment schedule.10 The guideline contains recommendations for treatment and graded
Identification and assessment of evidence
A Medline search was performed covering 1963 to August 2007 looking for the following terms in the title or
abstract: ‘pelvic inflammatory disease’, ‘adnexitis’, ‘oophoritis’, ‘parametritis’, ‘salpingitis’ or ‘adnexal disease’
(the dataset for 1963–86 was limited to Argonne Information Management journals and human subjects); 7211
citations were identified. A search of the Cochrane database revealed no directly relevant systematic reviews.
A search of the Cochrane controlled trials register using a search strategy of ‘pelvic inflammatory disease’,
‘adnexitis’, ‘oophoritis’, ‘parametritis’, ‘salpingitis’ or ‘adnexal disease’ identified 356 citations. The following
guidelines and reports were also reviewed: 2006 US Centers for Disease Control STD treatment guidelines,11
Royal College of Obstetrics and Gynaecology Study Group proceedings on PID 1996,1 2004 Health
Technology Assessment report, The Clinical Effectiveness and Cost Effectiveness of Antibiotic Regimens forPelvic Inflammatory Disease,12 2005 UK National Guidelines on Sexually Transmitted Diseases13 and 2007
European guidelines for the management of pelvic inflammatory disease.14
The recommendations given in this guideline have been graded according to the guidance for the
development of RCOG Green-top Guidelines.3. Making a diagnosis of acute PIDA low threshold for empiric treatment of PID is recommended because of the lack of definitive clinicaldiagnostic criteria and because the potential consequences of not treating of PID are significant. Inclinically severe cases, referral to hospital for treatment and further investigation is advisable.
The following clinical features are suggestive of a diagnosis of PID:
bilateral lower abdominal tenderness (sometimes radiating to the legs)
abnormal vaginal bleeding (intermenstrual, postcoital or ‘breakthrough’)
cervical motion tenderness on bimanual vaginal examination
adnexal tenderness on bimanual vaginal examination (with or without a palpable mass).
Clinical symptoms and signs lack sensitivity and specificity (the positive predictive value of a
clinical diagnosis is 65–90% compared with laparoscopic diagnosis but laparoscopy may also lack
sensitivity).15–18 The presence of excess leucocytes on a wet-mount vaginal smear is associated with
PID19,20 but is also found in women with isolated lower genital tract infection.
Laparoscopy enables specimens to be taken from the fallopian tubes and the pouch of Douglas and
can provide information on the severity of the condition.2,21 Although it has been considered the
gold standard in many studies of treatment regimens, 15–30% of suspected cases may have no
laparoscopic evidence of acute infection, despite organisms being identified from the fallopian
tubes.2,16,17 When there is diagnostic doubt laparoscopy may, however, be useful to exclude
Transvaginal ultrasound scanning may be helpful when there is diagnostic difficulty. When
supported by power Doppler, it can identify inflamed and dilated tubes and tubo-ovarian masses.
It may differentiate PID from acute appendicitis in a minority of cases but there is insufficient
evidence to support its routine use.22,23 Computed tomography24 and magnetic resonance
imaging25–27 can assist in making a diagnosis but the evidence is limited. A peripheral blood leuco-
cytosis, elevated erythrocyte sedimentation rate or C-reactive protein also support the diagnosis
and can provide a useful measure of disease severity28 but these are non-specific findings. There is
insufficient evidence to support endometrial biopsy as a routine diagnostic test at present.29,30
The differential diagnosis of lower abdominal pain in a young woman includes:
irritable bowel syndrome (and, less commonly, other gastrointestinal disorders)
complications of an ovarian cyst, such as rupture or torsion
functional pain (pain of unknown physical origin).Women with suspected PID should be tested for gonorrhoea and chlamydia.
Although not a prerequisite to justify initial treatment decisions, testing for gonorrhoea and
chlamydia in the lower genital tract is recommended. A positive result gives support to the clinical
diagnosis of PID and reinforces the need to treat sexual partners. The absence of confirmed
infection in the lower genital tract site does not exclude PID.2,11,16
Testing for gonorrhoea should be with an endocervical specimen and tested via culture (direct
inoculation on to a culture plate or transport of swab to laboratory within 24 hours) or using a
nucleic acid amplification test (NAAT). If gonorrhoea is detected using a NAAT, an additional
endocervical swab should be taken for gonococcal culture to allow the reporting of antibiotic
sensitivities and revision of therapy if required (women at high risk of gonorrhoea should have an
endocervical swab for gonococcal culture taken at their first examination; for example, where the
woman’s partner has gonorrhoea, clinically severe disease, sexual contact abroad).
Testing for chlamydia should also be from the endocervix, preferably using a NAAT (such as
polymerase chain reaction, strand displacement amplification).
Taking an additional sample from the urethra can increase the diagnostic yield for gonorrhoea and
chlamydia but is only recommended if the more sensitive NAAT is not available. A first catch urine
or self-taken vulvovaginal swab sample provides an alternative sample for some NAATs.31
The absence of endocervical or vaginal pus cells on a wet-mount smear has a good negative
predictive value (95%) for a diagnosis of PID but their presence is non-specific (poor positive
Other organisms, including M. genitalium,4,33–35 have been associated with PID but routine screening
is not yet justified because of limited information on prevalence, natural history, treatment and cost
Further advice on the appropriate testing for STIs is available from the National Screening andTesting Guidelines for Sexually Transmitted Infections (www.bashh.org/guidelines).Starting treatment4.1 How should PID be managed in the outpatient setting?Information on current and recent medication should be obtained.Interactions between antibiotic therapy and hormonal contraception and other patient medicationsshould be assessed and appropriate action taken.48Outpatient antibiotic treatment should be commenced as soon as the diagnosis is suspected.
In mild or moderate PID (in the absence of a tubo-ovarian abscess) there is no difference in
outcome when women are treated as outpatients or admitted to hospital.37 It is likely that delaying
treatment, especially in chlamydia infections, increases the severity of the condition and the risk of
long-term sequelae such as ectopic pregnancy, subfertility and pelvic pain.7,8
Outpatient antibiotic treatment should be based on one of the following regimens:oral ofloxacin 400 mg twice daily plus oral metronidazole 400 mg twice daily for 14 days38–41intramuscular ceftriaxone 250 mg single dose,* followed by oral doxycycline 100 mg twice daily plusmetronidazole 400 mg twice daily for 14 days.38,39,42–44* Cefoxitin has a better evidence base for the treatment of PID than ceftriaxone but is not easily available in theUK. Ceftriaxone is therefore recommended.
Broad-spectrum antibiotic therapy is generally required to cover N. gonorrhoeae, C. trachomatis and
anaerobic infection.1,2,11 Ofloxacin should be avoided in women who are at high risk of gonococcal
PID because of increasing quinolone resistance in the UK. Those women at high risk of acquiring
gonorrhoea include those whose partner has gonorrhoea, in clinically severe disease or if there is
Metronidazole may be discontinued in those women with mild or moderate PID who are unable
to tolerate it, since its addition provides uncertain additional efficacy in this patient group.
Clinical trial evidence for the following regimen is less strong but it may be used as an alternative
intramuscular ceftriaxone 250 mg immediately, followed by azithromycin 1 g/week for 2 weeks.45,46
Although the combination of oral doxycycline and metronidazole (without ceftriaxone) has been
used to treat PID in the UK, there are no clinical trials adequately assessing its effectiveness and its
use in isolation is not recommended.10,39,47 Data supporting azithromycin monotherapy for PID is
also limited at present and its use without the addition of ceftriaxone is not recommended.
There are currently no randomised controlled trial data to support the use of an oral (rather than
parenteral) cephalosporin as part of the treatment regimen. Tissue levels of the antibiotic are likely
to be lower following oral administration.A detailed explanation of their condition should be provided to women, with particular emphasis on thelong-term implications for their health and the health of their partner(s). This should be reinforced withclear and accurate written information.
When giving information to patients, the clinician should consider the following:
an explanation of what treatment is being given and its possible adverse effects
that following treatment fertility is usually maintained but there remains a risk of future infertility, chronic pelvic
repeat episodes of PID are associated with an exponential increase in the risk of infertility
future use of barrier contraception will significantly reduce the risk of PID
the need to screen her sexual contacts for infection to prevent her becoming reinfected
clinically more severe disease is associated with a greater risk of sequelae
the earlier treatment is given the lower the risk of future fertility problems.
A suitable patient information leaflet for PID is available at: www.rcog.org.uk/resources/public/pdf/Acute_
4.2 What hospital treatment should be given and when should it be recommended?
Admission to hospital would be appropriate in the following circumstances:11
Inpatient antibiotic treatment should be based on intravenous therapy which should be continued until24 hours after clinical improvement and followed by oral therapy.Recommended regimens are:ceftriaxone 2 g by intravenous infusion daily plus intravenous doxycycline 100 mg twice daily,* followed by oraldoxycycline 100 mg twice daily plus oral metronidazole 400 mg twice daily for a total of 14 days 11,38,39,43,44* Oral doxycycline may be used if tolerated.intravenous clindamycin 900 mg three times daily plus intravenous gentamicin,* followed by eitheroral clindamycin 450 mg four times daily to complete 14 daysORoral doxycycline 100 mg twice daily plus oral metronidazole 400 mg twice daily to complete 14 days.11,39,43,44* Gentamicin should be given as a 2 mg/kg loading dose followed by 1.5 mg/kg three times daily [or a singledaily dose of 7 mg/kg may be substituted].intravenous ofloxacin 400 mg twice daily plus intravenous metronidazole 500 mg three times daily for 14 days.38,39,49
The clinical trial data support the use of cefoxitin for the treatment of PID but this agent is not easily available
in the UK so ceftriaxone, which has a similar spectrum of activity, is recommended. An alternative third-
generation cephalosporin would also be acceptable.
Intravenous doxycycline is available from IDIS World Medicines (+44 [0] 1932 824000). If parenteral
gentamicin is used then serum drug levels and renal function should be monitored.
The choice of an appropriate treatment regimen will be influenced by robust evidence on local antimicrobial
sensitivity patterns, robust evidence on the local epidemiology of specific infections, cost, the woman’s
preference and compliance and severity of disease.
Evidence of the efficacy of antibiotic therapy in preventing the long-term complications of PID is currently
4.3 Treatment in pregnancy and in young women
A pregnancy test should be performed in all women suspected of having PID to help exclude an ectopic
pregnancy. When the risk of ectopic pregnancy is judged clinically to be high, the pregnancy test should be
repeated 21 days after the date of last unprotected intercourse.
The risk of giving any of the recommended antibiotic regimens in very early pregnancy (before a positive
pregnancy test) is low, since significant drug toxicity results in failed implantation (UK National Teratology
PID is rare in women with an intrauterine pregnancy except in the case of septic abortion. In septic abortion,
the infective organism is unlikely to be a sexually transmitted pathogen. Cervicitis may, however, occur in a
pregnancy and is associated with increased maternal and fetal morbidity. Treatment regimens will be dependent
upon the organisms isolated. Drugs known to be toxic in pregnancy, such as tetracyclines, should be avoided.
A combination of cefotaxime, azithromycin and metronidazole for 14 days may be used. The risks associated
with metronidazole are uncertain but no confirmed associations with adverse outcomes have been reported.
Ofloxacin should be avoided, where possible, in young women, when bone development is still occurring.
However, this recommendation is based on data from animal studies and no problems have been reported in
human subjects, so the British National Formulary currently recommends that ofloxacin may be used in
children where other options are limited. Doxycycline can be safely used in children over the age of 12 years.
A particularly low threshold for diagnosing and treating PID in women under the age of 25 years is
appropriate, owing to the higher incidence of disease in this group and the potential impact on future fertility.4.4 Treatment in a woman with an intrauterine contraceptive deviceConsideration should be given to removing an intrauterine contraceptive device (IUD) in womenpresenting with PID, especially if symptoms have not resolved within 72 hours.
The randomised controlled trial evidence for whether an IUD should be left in place or removed
in women presenting with PID is limited.50,51 Removal of the IUD should be considered and may be
associated with better short-term clinical outcomes but the decision to remove it needs to be
balanced against the risk of pregnancy in those who have had otherwise unprotected intercourse
in the preceding 7 days. Hormonal emergency contraception may be appropriate for some women
Other modes of treatmentSurgical treatment should be considered in severe cases or where there is clear evidence of a pelvicabscess.Consider drainage of an abscess and in noting its position, the possibility that the abscess may havearisen from the appendix or colon.
Laparoscopy may help early resolution of the disease by division of adhesions and drainage of
pelvic abscesses.52 Ultrasound-guided aspiration of pelvic fluid collections is less invasive and may
Management of sexual partner(s) of women with PID When a sexually transmitted infection is either proven or likely to be the cause of PID, the current sexualpartner(s) should be contacted and offered health advice and screening for gonorrhoea and chlamydia.
Other recent sexual partners may also be offered screening. Tracing of sexual partners within a 6-
month period of the onset of symptoms is recommended but this time period may be influenced
by the sexual history. The risk of detecting STIs in the partners of women with PID is high.2 Women
should be advised to avoid intercourse until they and their partner have completed the treatment
course. Gonorrhoea diagnosed in their sexual partner should be treated appropriately and
concurrently with the index woman. Concurrent empirical treatment for chlamydia is
recommended for all sexual partners, owing to the variable sensitivity of currently available
diagnostic tests. If adequate screening for gonorrhoea and chlamydia in the sexual partner(s) is not
possible, empirical therapy for both gonorrhoea and chlamydia should be given.55,56 Currently
recommended regimens are available at www.bashh.org. Tracing of sexual partners is not required
where a non-sexually transmitted pathogen has been clearly identified as the cause of infection.Referral of the index woman and her partner to a genitourinary medicine/sexual health clinic isrecommended to facilitate contact tracing and infection screening.Review of women with PIDIn the outpatient setting, review at 72 hours is recommended, particularly for those with a moderate orsevere clinical presentation.
Failure to improve clinically suggests the need for further investigation, to exclude competing diagnoses, and
may require admission for parenteral therapy and/or surgical intervention.
Further review 4–6 weeks after therapy may be useful to ensure:
screening and treatment of sexual contacts
awareness of the significance of PID and its sequelae
that a repeat pregnancy test is negative, if clinically indicated.
Repeat testing for gonorrhoea after treatment is recommended in those initially found to be
infected unless sensitivity testing of the isolate confirms sensitivity to the prescribed antibiotic.
Repeat testing for chlamydia and gonorrhoea is appropriate in those in whom persisting
symptoms, compliance with antibiotics and/or tracing of sexual contacts indicate the possibility of
A repeat chlamydia and gonorrhoea test is not otherwise required.Women who are infected with HIVWomen with PID who are also infected with HIV should be treated with the same antibiotic regimens aswomen who are HIV negative.
Women who are infected with HIV may have clinically more severe PID but respond equally well
to treatment as women who are not infected.57–59 Standard antibiotic treatment as outlined above is
therefore appropriate and hospital admission is only required for those with clinically severe
disease. Potential interactions between antibiotics and antiretroviral medication need to be
considered on an individual basis (information on drug interactions with antiretroviral drugs is
available at www.hiv-druginteractions.org).Women with HIV should be managed in conjunction with their HIV physician.Contraception options and PIDWomen on hormonal contraception presenting with breakthrough bleeding should be screened forgenital tract infection, especially C. trachomatis.
The use of the combined oral contraceptive pill has usually been regarded as protective against symptomatic
PID.60 Retrospective case–control and prospective studies have, however, shown an association with an
increased incidence of asymptomatic cervical infection with C. trachomatis.61 This has led to the suggestion
that the oral contraception may mask endometritis.62
An IUD only increases the risk of developing PID in the first few weeks after insertion.63 One European
randomised trial compared efficacy and continuation rates of copper-containing IUDs and the levonorgestrel-
releasing intrauterine system (LNG-IUS). At 3 years, there were significantly fewer removals for PID in the
All women diagnosed with PID should be provided with information about future contraceptive options and
should be assisted in making an informed choice.If a woman is likely to be at risk of future PID and requests an IUD for contraception, the LNG-IUS wouldbe the most appropriate choice53Auditable standards
Little is known about the long-term outcomes, in relation to future fertility, ectopic pregnancy and chronic
pelvic pain, following the treatment of PID. Appropriate short-term audit outcomes include:13
1. Proportion of women receiving treatment with a recommended regimen – target 95%.
2. Proportion of women referred for tracing of sexual contacts – target 95%.
3. Proportion of named male contacts in STI associated PID confirmed to have been screened for infection and/or
4. Proportion of women having an adequate sexual history documented – target 95%.
5. Proportion of women in whom microbiological investigations have been taken – target 90%.
For service organisation, please see: Royal College of Obstetricians and Gynaecologists. Standards inGynaecology. Report of a Working Party. 2008 [www.rcog.org.uk/resources/public/pdf/GYNStandardsWPR
References
Recommendations arising from the 31st Study Group: The
10. Ross JD. Outpatient antibiotics for pelvic inflammatory disease.
Prevention of Pelvic Infection. In: Templeton A, editor. The Pre-vention of Pelvic Infection. London: RCOG Press; 1996. 267–70.
11. US Centers for Disease Control. Sexually Transmitted Diseases
Bevan CD, Johal BJ, Mumtaz G, Ridgway GL, Siddle NC. Clinical,
Treatment Guidelines 2006. MMWR Morb Mort Wkly Rep
laparoscopic and microbiological findings in acute salpingitis:
report on a United Kingdom cohort. Br J Obstet Gynaecol
12. Meads C, Knight T, Hyde C, Wilson J. The clinical effectiveness
and cost effectiveness of antibiotic regimens for pelvic inflam-
Baveja G, Saini S, Sangwan K, Arora DR. A study of bacterial
matory disease. 2004. West Midlands Health Technology Assess-
pathogens in acute pelvic inflammatory disease. J Commun Dis
ment Collaboration, University of Birmingham [www.rep.bham.
ac.uk/2004/Pelvic_Inflammatory_Disease.pdf].
Simms I, Eastick K, Mallinson H, Thomas K, Gohhale R, Hay PE, et
13. Ross JDC. British Association for Sexual Health and HIV UK
al. Associations between Mycoplasma genitalium, Chlamydia
National Guidelines for the Management of Pelvic Inflammatory
trachomatis and pelvic inflammatory disease. Sex Transm
Disease. 2005 [www.bashh.org/documents/118/118.pdf].
14. Ross JD, Judlin P, Nilas L. European guideline for the management
Haggerty CL, Hillier SL, Bass DC, Ness RB. PID Evaluation and
of pelvic inflammatory disease. Int J STD AIDS 2007;18:662–6.
Clinical Health study investigators. Bacterial vaginosis and
15. Gaitan H, Angel E, Diaz R, Parada A, Sanchez L, Vargas C. Accuracy
anaerobic bacteria are associated with endometritis. Clin Infect
of five different diagnostic techniques in mild-to-moderate
pelvic inflammatory disease. Infect Dis Obstet Gynecol.
Simms I, Vickers MR, Stephenson J, Rogers PA, Nicoll A.
National assessment of PID diagnosis, treatment and manage-
16. Morcos R, Frost N, Hnat M, Petrunak A, Caldito G. Laparoscopic
ment in general practice: England and Wales. Int J STD AIDS
versus clinical diagnosis of acute pelvic inflammatory disease. J
Hillis SD, Joesoef R, Marchbanks PA, Wasserheit JN, Cates W Jr,
17. Cibula D, Kuzel D, Fucikova Z, Svabik K, Zivny J. Acute
Westrom L, et al. Delayed care of pelvic inflammatory disease as
exacerbation of recurrent pelvic inflammatory disease.
a risk factor for impaired fertility. Am J Obstet Gynecol
Laparoscopic findings in 141 women with a clinical diagnosis. J
Lepine LA, Hillis SD, Marchbanks PA, Joesoef MR, Peterson HB,
18. Molander P, Finne P, Sjoberg J, Sellors J, Paavonen J. Observer
Westrom L. Severity of pelvic inflammatory disease as a
agreement with laparoscopic diagnosis of pelvic inflammatory
predictor of the probability of live birth. Am J Obstet Gynecol
disease using photographs. Obstet Gynecol 2003;101:875–80.
19. Peipert JF, Ness RB, Blume J, Soper DE, Holley R, Randall H, et al.
Yeh JM, Hook EW 3rd, Goldie SJ. A refined estimate of the
Clinical predictors of endometritis in women with symptoms
average lifetime cost of pelvic inflammatory disease. Sex Transm
and signs of pelvic inflammatory disease. Am J Obstet Gynecol
20. Hakakha MM, Davis J, Korst LM, Silverman NS. Leukorrhea and
42. Arredondo JL, Diaz V, Gaitan H, Maradiegue E, Oyarzun E, Paz R,
bacterial vaginosis as in-office predictors of cervical infection in
et al. Oral clindamycin and ciprofloxacin versus intramuscular
high-risk women. Obstet Gynecol 2002;100:808–12.
ceftriaxone and oral doxycycline in the treatment of mild-to-
21. Kinghorn GR, Duerden BI, Hafiz S. Clinical and microbiological
moderate pelvic inflammatory disease in outpatients. Clin Infect
investigation of women with acute salpingitis and their
consorts. Br J Obstet Gynaecol 1986;93:869–80.
43. Hemsell DL, Little BB, Faro S, Sweet RL, Ledger WJ, Berkeley AS,
22. Molander P, Sjoberg J, Paavonen J, Cacciatore B. Transvaginal power
et al. Comparison of three regimens recommended by the
Doppler findings in laparoscopically proven acute pelvic inflam-
Centers for Disease Control and Prevention for the treatment of
matory disease. Ultrasound Obstet Gynecol 2001;17:233–8.
women hospitalized with acute pelvic inflammatory disease.
23. Taipale P, Tarjanne H, Ylostalo P. Transvaginal sonography in
Clin Infect Dis 1994;19:720–7.
suspected pelvic inflammatory disease. Ultrasound Obstet
44. The European Study Group. Comparative evaluation of
clindamycin/gentamicin and cefoxitin/doxycycline for treatment
24. Bennett GL, Slywotzky CM, Giovanniello G. Gynecologic causes
of pelvic inflammatory disease: a multi-center trial. Acta Obstet
of acute pelvic pain: spectrum of CT findings. RadiographicsGynecol Scand 1992;71:129–34.
45. Savaris RF, Teixeira LM, Torres TG, Edelweiss MI, Moncada J,
25. Tukeva TA, Aronen HJ, Karjalainen PT, Molander P, Paavonen T,
Schachter J. Comparing ceftriaxone plus azithromycin or
Paavonen J. MR imaging in pelvic inflammatory disease: com-
doxycycline for pelvic inflammatory disease: a randomized
parison with laparoscopy and US. Radiology 1999;210:209–16.
controlled trial. Obstet Gynecol 2007;110:53–60.
26. Imaoka I, Wada A, Matsuo M, Yoshida M, Kitagaki H, Sugimura K. MR
46. Bevan CD, Ridgway GL, Rothermel CD. Efficacy and safety of
imaging of disorders associated with female infertility: use in diag-
azithromycin as monotherapy or combined with metronidazole
nosis, treatment, and management. Radiographics 2003;23:1401–21.
compared with two standard multidrug regimens for the
27. Nishino M, Hayakawa K, Iwasaku K, Takasu K. Magnetic
treatment of acute pelvic inflammatory disease. J Int Med Res
resonance imaging findings in gynecologic emergencies. JComput Assist Tomogr 2003;27:564–70.
47. Piyadigamage A, Wilson J. Improvement in the clinical cure rate
28. Miettinen AK, Heinonen PK, Laippala P, Paavonen J. Test
of outpatient management of pelvic inflammatory disease follow-
performance of erythrocyte sedimentation rate and C- reactive
ing a change in therapy. Sex Trans Infect 2005;81:233–5.
protein in assessing the severity of acute pelvic inflammatory
48. FFPRHC Guidance: Drug interactions with hormonal contra-
disease. Am J Obstet Gynecol 1993;169:1143–9.
ception. J Fam Plann Reprod Health Care 2005;31:139–51.
29. Wiesenfeld HC, Hillier SL, Krohn MA, Amortegui AJ, Heine RP,
49. Witte EH, Peters AA, Smit IB, van der Linden MC, Mouton RP, van
Landers DV, et al. Lower genital tract infection and endometritis:
der Meer JW, et al. A comparison of pefloxacin/metronidazole
insight into subclinical pelvic inflammatory disease. Obstet
and doxycycline/metronidazole in the treatment of laparoscop-
ically confirmed acute pelvic inflammatory disease. Eur J Obstet
30. Ross JD. What is endometritis and does it require treatment? SexGynecol Reprod Biol 1993;50:153–8.Transm Infect 2004;80:252–3.
50. Soderberg G, Lindgren S. Influence of an intrauterine device on the
31. Ross JD, Ison CA. UK National Screening and Testing Guidelines
course of an acute salpingitis. Contraception 1981; 24:137-143.
for STIs. Sex Transm Infect 2006;82 Suppl IV:1–5.
51. Altunyurt S, Demir N, Posaci C. A randomized controlled trial of
32. Yudin MH, Hillier SL, Wiesenfeld HC, Krohn MA, Amortegui AA,
coil removal prior to treatment of pelvic inflammatory disease.
Sweet RL. Vaginal polymorphonuclear leukocytes and bacterial
Eur J Obstet Gynecol Reprod Biol 2003;107:81–4.
vaginosis as markers for histologic endometritis among women
52. Reich H, McGlynn F. Laparoscopic treatment of tuboovarian and
without symptoms of pelvic inflammatory disease. Am J Obstet
pelvic abscess. J Reprod Med 1987;32:747–52.
53. Aboulghar MA, Mansour RT, Serour GI. Ultrasonographically
33. Clausen HF, Fedder J, Drasbek M, Nielsen PK, Toft B, Ingerslev HJ,
guided transvaginal aspiration of tuboovarian abscesses and
et al. Serological investigation of Mycoplasma genitalium in
pyosalpinges: an optional treatment for acute pelvic
infertile women. Hum Reprod 2001;16:1866–74.
inflammatory disease. Am J Obstet Gynecol 1995;172:1501–3.
34. Jensen JS. Mycoplasma genitalium infections. Diagnosis, clinical
54. Corsi PJ, Johnson SC, Gonik B, Hendrix SL, McNeeley SG Jr.,
aspects, and pathogenesis. Dan Med Bull 2006;53:1–27.
Diamond MP. Transvaginal ultrasound-guided aspiration of pelvic
35. Haggerty CL, Totten PA, Astete SG, Ness RB. Mycoplasma genita-
abscesses. Infect Dis Obstet Gynecol 1999;7:216–21.
lium among women with nongonococcal, nonchlamydial pelvic
55. Haddon L, Heason J, Fay T, McPherson M, Carlin EM, Jushuf IH.
inflammatory disease. Infect Dis Obstet Gynecol 2006;30184:1–5.
Managing STIs identified after testing outside genitourinary
36. Ross JDC, Jensen JS. Mycoplasma genitalium as a sexually
medicine departments: one model of care. Sex Transm Infect
transmitted infection: Implications for screening, testing, and
treatment. Sex Transm Infect 2006;82:269–71.
56. Groom TM, Stewart P, Kruger H, Bell G. The value of a screen and
37. Ness RB, Soper DE, Holley RL, Peipert J, Randall H, Sweet RL, et al.
treat policy for Chlamydia trachomatis in women attending for
Effectiveness of inpatient and outpatient treatment strategies for
termination of pregnancy. J Fam Plann Reprod Health Care
women with pelvic inflammatory disease: results from the Pelvic
Inflammatory Disease Evaluation and Clinical Health (PEACH)
57. Bukusi EA, Cohen CR, Stevens CE, Sinei S, Reilly M, Grieco V, et al.
Randomized Trial. Am J Obstet Gynecol 2002;186:929–37.
Effects of human immunodeficiency virus 1 infection on micro-
38. Martens MG, Gordon S, Yarborough DR, Faro S, Binder D,
bial origins of pelvic inflammatory disease and on efficacy of am-
Berkeley A. Multicenter randomized trial of ofloxacin versus
bulatory oral therapy. Am J Obstet Gynecol 1999;181:1374–81.
cefoxitin and doxycycline in outpatient treatment of pelvic
58. Cohen CR, Sinei S, Reilly M, Bukusi E, Eschenbach D, Holmes KK,
inflammatory disease. Ambulatory PID Research Group.et al. Effect of human immunodeficiency virus type 1 infection
Southern Med J 1993;86:604–10.
upon acute salpingitis: a laparoscopic study. J Infect Dis
39. Walker CK, Kahn JG, Washington AE, Peterson HB, Sweet RL.
Pelvic inflammatory disease: metaanalysis of antimicrobial
59. Irwin KL, Moorman AC, O'Sullivan MJ, Sperling R, Koestler ME,
regimen efficacy. J Infect Dis 1993;168:969–78.
Soto I, et al. Influence of human immunodeficiency virus
40. Soper DE, Brockwell NJ, Dalton HP. Microbial etiology of urban
infection on pelvic inflammatory disease. Obstet Gynecol
emergency department acute salpingitis: treatment with
ofloxacin. Am J Obstet Gynecol 1992;167:653–60.
60. Vessey MP. Epidemiologic studies of oral contraception. Int J
41. Peipert JF, Sweet RL, Walker CK, Kahn J, Rielly-Gauvin K.Fertil 1989;34 Suppl:64–70.
Evaluation of ofloxacin in the treatment of laparoscopically
61. Cottingham J, Hunter D. Chlamydia trachomatis and oral
documented acute pelvic inflammatory disease (salpingitis).
contraceptive use: a quantitative review. Genitourin MedInfect Dis Obstet Gynecol 1999;7:138–44.
62. Rice PA, Schachter J. Pathogenesis of pelvic inflammatory
64. Toivonen J, Luukkainen T, Allonen H. Protective effect of
disease. What are the questions? JAMA 1991;266:2587–93.
intrauterine release of levonorgestrel on pelvic infection:three
63. Grimes DA. Intrauterine device and upper-genital-tract infection.
years’ comparative experience with levonorgestrel- and copper-
releasing intrauterine devices. Obstet Gynecol 1991;77:261–4.APPENDIX
Clinical guidelines are: ‘systematically developed statements which assist clinicians and patients in
making decisions about appropriate treatment for specific conditions’. Each guideline is systematically
developed using a standardised methodology. Exact details of this process can be found in Clinical
Governance Advice No. 1: Development of RCOG Green-top Guidelines (available on the RCOG website
at www.rcog.org.uk/index.asp?PageID=75). These recommendations are not intended to dictate an
exclusive course of management or treatment. They must be evaluated with reference to individual
patient needs, resources and limitations unique to the institution and variations in local populations. It is
hoped that this process of local ownership will help to incorporate these guidelines into routine
practice. Attention is drawn to areas of clinical uncertainty where further research may be indicated.
The evidence used in this guideline was graded using the scheme below and the recommendations
formulated in a similar fashion with a standardised grading scheme.Classification of evidence levelsGrades of recommendations
1++ High-quality meta-analyses, systematic
At least one meta-analysis, systematic reviews
reviews of randomised controlled trials or
or randomised controlled trial rated as 1++
randomised controlled trials with a very low
A systematic review of randomised controlled
principally of studies rated as 1+, directly
applicable to the target population anddemonstrating overall consistency of results
Meta-analyses, systematic reviews ofrandomised controlled trials or
A body of evidence including studies rated as
population and demonstrating overallconsistency of results; or
Extrapolated evidence from studies rated as
case–control or cohort studies or high-
quality case–control or cohort studieswith a very low risk of confounding, bias
A body of evidence including studies rated as
or chance and a high probability that the
2+ directly applicable to the target population
and demonstrating overall consistency ofresults; or
Extrapolated evidence from studies rated as
bias or chance and a moderate prob-ability that the relationship is causal
Extrapolated evidence from studies rated as
high risk of confounding, bias or chanceand a significant risk that therelationship is not causal
Good practice point
Non-analytical studies; e.g. case reports,
This guideline was produced on behalf of the Guidelines Committee of the Royal College of Obstetricians
and Gynaecologists and the British Association for Sexual Health and HIV (BASHH) by:Prof J Ross MD FRCP, Birmingham (BASHH) and Mr P Stewart FRCOG, Sheffield (RCOG)
BASHH, Ms J Birch, J Birch, Pelvic Pain Support Network; Mr CD Bevan FRCOG, Weston Super Mare;
RCOG Consumers’ Forum; Dr GE Forster FRCOG, London; Dr PE Munday FRCOG, Watford;
Professor J Paavonen, Helsinki; Dr J Paton, Consultant Microbiologist, Queens Hospital, Burton upon Trent;
Dr JT Preston FRCOG, Great Yarmouth.
The Guidelines Committee lead reviewers were:
Dr MR Gazvani FRCOG, Liverpool; Ms T Belfield, Consumers’ Forum Representative, Family Planning
Association, and Mr S Leeson FRCOG, Bangor, Wales.
The final version is the responsibility of the Guidelines Committee of the RCOG.
The guideline review process will commence in 2011
The following changes were made to the published document January 2009:
Section 4.4 Treatment in a woman with an intrauterine contraceptive deviceConsideration should be given to removing an intrauterine contraceptive device (IUD) in womenpresenting with PID, especially if symptoms have not resolved within 72 hours.Section 5. Other modes of treatmentConsider drainage of an abscess and in noting its position, the possibility that the abscess may havearisen from the appendix or colon.
The Royal College of Obstetricians and Gynaecologists produces guidelines as an educational aid to good clinicalpractice. They present recognised methods and techniques of clinical practice, based on published evidence, forconsideration by obstetricians and gynaecologists and other relevant health professionals. The ultimate judgementregarding a particular clinical procedure or treatment plan must be made by the doctor or other attendant in the lightof clinical data presented by the patient and the diagnostic and treatment options available.
This means that RCOG Guidelines are unlike protocols or guidelines issued by employers, as they are not intended tobe prescriptive directions defining a single course of management. Departure from the local prescriptive protocols orguidelines should be fully documented in the patient’s case notes at the time the relevant decision is taken.

Clinical Management of Cytotoxic Drug Overdoses in Companion Animals Valerie Wiebe and Eric Simonson In general, companion animals tolerate chemotherapy exceptionally well, with far fewer side effects than their human counterparts. This is primarily due to the lower doses used in veterinary species (well below the maximum tolerated dose in people) and the less frequent use of multimodalit